anemia
A.
Definition
Anemia
is a symptom of an underlying condition, such as loss of blood components, the
elements do not adequately or lack of nutrients needed for the formation of red
blood cells, resulting in decreased oxygen-carrying capacity of blood (Doenges,
1999).
Anemia
is a term that indicates low red blood cell count and hemoglobin and hematocrit
levels below normal (Smeltzer, 2002: 935).
Anemia
is reduced to below the normal value of red blood cells, hemoglobin and quality
Bloods volume of packed red cells (hematocrit) per 100 ml of blood (Price,
2006: 256).
Thus,
anemia is not a diagnosis or a disease, but rather a reflection of the state of
a disease or impaired function of the body and changes the fundamental
patotisiologis anemnesis described through a thorough, physical examination and
laboratory information.
B.
Etiology
The
most common cause of anemia is a lack of nutrients necessary for the synthesis
of erythrocytes, including iron, vitamin B12 and folic acid. The rest is the
result of a variety of conditions such as hemorrhage, genetic abnormalities,
chronic disease, drug toxicity, and so on.
A
common cause of anemia:
•
Bleeding great
•
Acute (sudden)
•
Accidents
•
Surgery
•
Childbirth
•
Broken blood vessels
•
Chronic disease (chronic)
•
Bleeding nose
•
Hemorrhoids (haemorrhoids)
•
Peptic ulcer
•
cancer or polyps in the gastrointestinal tract
•
kidney or bladder tumor
•
menstrual bleeding
•
Reduced red blood cell formation
•
Iron deficiency
•
Lack of vitamin B12
•
Lack of folic acid
•
Lack of vitamin C
•
Chronic Disease
•
Increased destruction of red blood cells
•
Enlargement of the spleen
•
mechanical damage to red blood cells
•
Autoimmune reactions to red blood cells
•
paroxysmal nocturnal Hemoglobinuria
•
Hereditary spherocytosis
•
Hereditary Elliptositosis
•
G6PD Deficiency
•
Sickle cell disease
•
hemoglobin C disease
•
S-hemoglobin C disease
•
hemoglobin E disease
•
Thalassemia (Burton, 1990).
C.
Pathophysiology
Incidence
of anemia reflects a failure of the bone marrow or excessive loss of red blood cells
or both. Bone marrow failure caused by lack of nutrients DAPT, toxic exposure,
inuasi tumor, or mostly due to unknown causes. Red blood cells can be lost
through bleeding or hemolysis (destruction) in the latter case, the problem can
be due to the effects of red blood cells that do not conform to the normal
resistance of red blood cells or due to some factor outside the red blood cells
that causes destruction of red blood cells.
Red
blood cell lysis (dissolution) occurs mainly in the phagocytic system or the
reticuloendothelial system, especially in the liver and spleen. As a byproduct
of this process is bilirubin is formed in phagocytes will enter the
bloodstream. Any increase in red blood cell destruction (hemolysis) immediately
direpleksikan with increasing plasma bilirubin (normal concentration of 1 mg /
dl or less; levels of 1.5 mg / dl cause jaundice in the sclera.
Anemia
is a blood disease characterized less low levels of hemoglobin (Hb) and red
blood cells (erythrocytes). The function of blood is to carry food and oxygen
to all organs of the body. If the supply is less, then the oxygen would be
less. As a result, the work can hinder vital organs, the brain One. The brain
consists of 2.5 billion cells bioneuron. If the capacity is less, then the brain
as a computer which weak memory, slow catch. And if it is damaged, it can not
be repaired (Sjaifoellah, 1998).
D.
Clinical Manifestations
Clinical
symptoms appear to reflect dysfunction of various systems in the body such as
decreased physical performance, neurological (nerve), which is manifested in
behavioral changes, anorexia (emaciated body), pica, and abnormal cognitive
development in children. Growth abnormalities often occur, epithelial
dysfunction, and reduced gastric acidity. An easy way to know anemia with 5L,
which is weak, tired, listless, tired, inattentive. If you have 5 of these
symptoms, we can be sure a person has anemia. Another symptom is the appearance
of the sclera (the pale color on the lower eyelid).
Anemia
can cause fatigue, weakness, lack of energy and the head was floating. If
anemia is more severe, it can cause a stroke or heart attack (Sjaifoellah,
1998).
E.
Complication
Anemia
also causes reduced endurance. As a result, patients will be susceptible to
infection with anemia. Easy colds, flu easily, or prone to respiratory
infections, heart also becomes easily tired, having to pump blood more
powerful. In the case of pregnant women with anemia, if slow and sustained
handled can lead to death, and the risk to the fetus. In addition to babies
born with low weight, anemia can also interfere with the development of organs,
including the brain (Sjaifoellah, 1998).
F.
Investigations
Complete
blood count (JDL): decreased hemoglobin and hemalokrit.
The
number of erythrocytes: decline (AP), decreased weight (aplastic), MCV (mean
corpuscular molume) and MCH (mean corpuscular hemoglobin) and microcytic with
decreased erythrocyte hipokronik (DB), increase (AP). Pancytopenia (aplastic).
Reticulocyte
count: varies, eg decreased (AP), an increase (bone marrow response to blood
loss / hemolysis).
Lipstick
red blood cells: detecting changes in color and shape (may indicate a special
type of anemia).
LED:
increase indicates an inflammatory reaction, eg, increased red blood cell
destruction: malignasi or disease.
The
life span of red blood cells: are useful in differentiating the diagnosis of
anemia, eg on a particular type of anemia, red blood cells have a shorter life
span.
Erythrocyte
fragility test: Down (DB).
SDP:
the total number of cells with red blood cells (differential) may increase
(hemolytic) or decreased (aplastic).
Platelet
count: decreased caplastik; increased (DB), normal or high (hemolytic)
Hemoglobin
electrophoresis: identify the type of the structure of hemoglobin.
Serum
bilirubin (unconjugated): increase (AP, hemolytic).
Serum
folate and vitamin B12 to help diagnose anemia deficiency in relation to the
input / absorption
Serum
iron: no (DB), height (hemolytic)
Tuberculosis
serum: increased (DB)
Serum
Ferritin: increased (DB)
Period
bleeding: elongated (aplastic)
Serum
LDH: Down (DB)
Schilling
test: decreased urinary excretion of vitamin B12 (AP)
Guaiak:
may be positive for blood in the urine, feces, and gastric contents, showing
bleeding acute / chronic (DB).
Gastric
Analysis: secretion decreased with increasing pH and the absence of free
hydrochloric acid (AP).
Bone
marrow aspiration / inspection / biopsy: cells may appear to change in number,
size, and shape, form, distinguishing the type of anemia, eg, increased
megaloblas (AP), fatty marrow with decreased blood cells (aplastic).
Andoskopik
and radiographic examination: check the bleeding: GI bleeding (Doenges, 1999).
G.
Medical Management
Common
actions:
Management
of anemia is shown to find the cause and replace the lost blood.
1.
Red blood cell transplantation.
2.
Antibiotics are given to prevent infection.
3.
Folic acid supplements can stimulate the formation of red blood cells.
4.
Avoid situations of oxygen deficiency or an activity that requires oxygen
5.
Treat the cause of abnormal bleeding if any.
6.
Iron-rich diet containing meat and green vegetables.
Treatment
(for treatment depending on the cause):
1.
Iron deficiency anemia
Management:
Set
the iron-containing foods, try the food given as fish, meat, eggs and
vegetables.
Giving
preparations fe
Perrosulfat
oral 200mg/hari/per 3x after meals
Peroglukonat
3x 200 mg / day / orally after meals.
2.
Pernicious Anemia: Vitamin B12
3.
Anemia Folic acid: Folic acid 5 mg / day / oral
4.
Anemia due to bleeding: the bleeding, and shock by administering fluids and
blood transfusions.
NURSING
MANAGEMENT
A.
Assessment
Assessment
is the first step in the process and basic nursing menyeluru (Boedihartono,
1994).
Assessment
of patients with anemia (Doenges, 1999) include:
1)
activity / rest
Symptoms:
fatigue, weakness, general malaise. Loss of productivity: a reduction in enthusiasm
for work. Low tolerance to exercise. The need for sleep and rest more.
Signs:
tachycardia / takipnae; dyspnea at work or rest. Lethargy, withdrawal, apathy,
lethargy, and lack of interest in the vicinity. Muscle weakness, and decreased
strength. Ataxia, body upright. Shoulders down, slumped posture, slow, and
other signs of fatigue menunujukkan.
2)
Circulation
Symptoms:
a history of chronic blood loss, such as chronic GI bleeding, heavy
menstruation (DB), angina, CHF (due to excessive cardiac work). History of
chronic infective endocarditis. Palpitations (tachycardia compensation).
Signs:
BP: systolic to diastolic steady improvement and widening pulse pressure,
postural hypotension. Dysrhythmias: ECG abnormalities, ST segment depression
and T wave flattening or depression; tachycardia. Heart murmurs: systolic
murmur (DB). Extremities (color): pale skin and mucous membranes (konjuntiva,
mouth, pharynx, lips) and nail bed. (Note: in black patients, may appear as a
pale grayish). Skin like a waxy, pale (aplastic, AP) or a bright lemon yellow
(AP). Sclera: blue or white as pearls (DB). Slowed capillary refill (decreased
blood flow to the capillaries and vasoconstriction compensation) nails: easily
broken, shaped like a spoon (koilonychia) (DB). Hair: dry, easily broken, thin,
prematurely gray hair grows (AP).
3)
Integrity ego
Symptoms:
keyakinanan religious / cultural influence treatment options, such as the
rejection of blood transfusions.
Signs:
depression.
4)
elimination
Symptoms:
a history of pyelonephritis, renal failure. Flatulen, malabsorption syndrome
(DB). Hematemesis, stool with fresh blood, melena. Diarrhea or constipation.
Decreased urine output.
Signs:
abdominal distension.
5)
Food / fluid
Symptoms:
feedback reduction diet, animal protein diet low input / high input cereal
products (DB). Painful mouth or tongue, difficulty swallowing (pharyngeal
ulcers). Nausea / vomiting, dyspepsia, anorexia. A decrease in body weight.
Never settle for chewing or sensitive to ice, dirt, corn flour, paint, clay,
etc. (DB).
Signs:
the tongue to appear red meat / smooth (AP; deficiency of folic acid and
vitamin B12). Dry mucous membranes, pale. Skin turgor: poor, dry, looks
wrinkled / lost elasticity (DB). Stomatitis and glossitis (deficiency status).
Lips: selitis, such as inflammatory lips cracked corners of the mouth. (DB).
6)
Neurosensori
Symptoms:
headache, throbbing, dizziness, vertigo, tinnitus, inability to concentrate.
Insomnia, decreased vision, and eye shadow. Weakness, poor balance, wobbly
legs; paresthesias hands / legs (AP); claudication. Manjadi cold sensation.
Signs:
sensitive stimuli, anxiety, depression tends to sleep, apathy. Mental: not able
to respond, slow and shallow. Ophthalmic: hemoragis retina (aplastic, AP).
Epitaksis: bleeding from the holes (aplastic). Impaired coordination, ataxia,
decreased sense of vibration and position, positive Romberg sign, paralysis
(AP).
7)
Pain / comfort
Symptoms:
Abdominal pain samara: headache (DB)
8)
Respiratory
Symptoms:
a history of tuberculosis, lung abscess. Shortness of breath at rest and
activity.
Signs:
tachypnea, orthopnea, and dyspnea.
9)
Security
Symptoms:
a history of work exposure to chemicals,. History of exposure to radiation;
well to treatment or accident. History of cancer, cancer therapies. Not
tolerant of cold and heat. Previous blood transfusion. Impaired vision, poor
wound healing, frequent infections.
Signs:
low fever, chills, night sweats, general lymphadenopathy. Ptekie and ecchymosis
(aplastic).
10)
Sexuality
Symptoms:
changes in menstrual flow, such as menorrhagia or amenorrhea (DB). Lost libido
(male and female). Imppoten.
Signs:
Cervical and vaginal walls pale.
B.
Nursing Diagnosis
Nursing
diagnosis is a unification of the problem of real or potential patients based
on the data collected (Boedihartono, 1994).
Nursing
diagnoses that appear in patients with anemia (Doenges, 1999) include:
1.
High risk of infection associated with an inadequate secondary defenses
(decreased hemoglobin leucopenia, or a decrease in granulocytes (inflammatory
response depressed)).
2.
Changes in nutrition less than body requirements related to the failure or inability
to digest digest food / nutrient absorption necessary for the formation of red
blood cells.
3.
Activity intolerance related to imbalance between oxygen supply (delivery) and
needs.
4.
Changes in tissue perfusion associated with decreased cellular components
required for the delivery of oxygen / nutrients to the cells.
5.
A high risk of damage to skin integrity related to changes in circulation and
neurologist.
6.
Constipation or diarrhea associated with lower dietary input; digestive process
changes; side effects of drug therapy.
7.
Lack of knowledge with respect to the lack of exposure / recall; incorrect
interpretation of information; does not know the source of information.
C.
Interventions / Implementation of nursing
Intervention
is planning nursing actions that will be implemented to address the problem in
accordance with the nursing diagnoses (Boedihartono, 1994)
Implementation
is the management and realization of the nursing plan that had been developed
at the planning stage (Effendi, 1995).
Implementation
of nursing interventions and patients with anemia (Doenges, 1999) are:
1)
High risk of infection related to an inadequate secondary defenses (decreased
hemoglobin leucopenia, or a decrease in granulocytes (inflammatory response
depressed)).
Objective:
Infection does not occur.
Criteria
results: - identify behaviors to prevent / reduce the risk of infection.
-
Improves wound healing, free purulent drainage or erythema, and fever.
INTERVENTION
& IMPLEMENTATION
Increase
good hand washing; by the care givers and patients.
Rational:
to prevent cross contamination / bacterial colonization. Note: patients with
severe anemia / aplastic can be risky due to the normal flora of the skin.
Maintain
strict aseptic technique on the procedure / treatment of wounds.
Rational:
to reduce the risk of colonization / infection of bacteria.
Give
skin care, oral and perianal carefully.
Rational:
reducing the risk of damage to the skin / tissue and infection.
Motivation
changes in position / ambulation often, coughing and deep breathing exercises.
Rationale:
increased pulmonary ventilation all segments and help mobilize secretions to
prevent pneumonia.
Increase
enter adequate fluids.
Rational:
to assist in the dilution secret breathing to ease spending and prevent stasis
of body fluids such as respiratory and kidney.
Monitor
/ limit visitors. Provide insulation where possible.
Rational:
limiting exposure to bacteria / infection. Protection of insulation required in
aplastic anemia, when the immune response is very disturbed.
Monitor
body temperature. Note the chills and tachycardia with or without fever.
Rational:
the process of inflammation / infection require evaluation / treatment.
Observe
erythema / wound fluid.
Rational:
indicators of local infection. Note: the formation of pus may not exist when
granulocytes depressed.
Take
a specimen for culture / sensitivity as indicated (collaboration)
Rational:
to distinguish the presence of infection, identify specific pathogens and
influence the choice of treatment.
Leave
a topical antiseptic; systemic antibiotics (collaboration).
Rational:
may be used to reduce colonization or prophylactic treatment for local
infection process.
2)
Changes in nutrition less than body requirements related to the failure or
inability to digest digest food / nutrient absorption necessary for the
formation of red blood cells.
Objective:
nutritional needs are met
Criteria
results: - menunujukkan increase / maintain your weight with normal laboratory
values.
-
No sign of mal nutrition experience.
-
To show for behavioral, lifestyle changes to improve and or maintain an
appropriate body weight.
INTERVENTION
& IMPLEMENTATION
Review
the history of nutrition, including eating favored.
Rational:
identifying deficiencies, facilitate intervention.
Observation
and record the patient's desired food.
Rational:
overseeing enter or quality of calorie consumption of food shortages.
Measure
your weight every day.
Rational:
overseeing the effectiveness of weight loss or nutritional interventions.
Give
eat little and often frequency or eat between meals.
Rational:
lowering weakness, increased intake and prevent gastric distention.
Observation
and record the incidence of nausea / vomiting, flatus and and other related
symptoms.
Rational:
GI symptoms may indicate the effect of anemia (hypoxia) in the organ.
Provide and good oral hygiene aids, before and after eating, use a soft
toothbrush for gentle brushing. Give dessert in dilute when oral mucosa injury.
Rationale:
increased appetite and oral intake. Lowering the growth of bacteria, minimizes
the chance of infection. Special oral care techniques may be needed when the
network brittle / injuries / bleeding and severe pain.
Collaboration
a nutritionist for a diet plan.
Rational:
diet plan to help meet individual needs.
Collaboration;
monitor laboratory test results.
Rationale:
Increasing the effectiveness of treatment programs, including dietary sources
of nutrients needed.
Collaboration;
give medication as indicated.
Rationale:
the need of replacement depends on the type of anemia and or poor oral adanyan
enter and deficiencies identified.
3)
Activity intolerance related to imbalance between oxygen supply (delivery) and
needs.
Objective:
to maintain / improve ambulation / activity.
Criteria
results: - reported increased tolerance activities (including activities of
daily living)
-
Showed a physiological sign of intolerance, such as pulse, respiration, and
blood pressure was within the normal range.
INTERVENTION
& IMPLEMENTATION
Assess
the patient's ADL ability.
Rational:
influencing choice of intervention / assistance.
Assess
loss or impaired balance, gait and muscle weakness.
Rational:
shows changes neurology of vitamin B12 deficiency affects patient safety / risk
of injury.
Observation
of vital signs before and after the activity.
Rational:
cardiopulmonary manifestations of heart and lung effort to bring adequate
amounts of oxygen to the tissues.
Provide
quiet environment, limit visitors, and reduce noise, maintain bed rest when it
is indicated.
Rational:
improving breaks to lower the body's need for oxygen and lowering strain the
heart and lungs.
Use the energy-saving techniques, instruct the patient a break when fatigue and
weakness occurs, instruct the patient did his best activity (without imposing
themselves).
Rational:
to increase gradually to normal activity and improve muscle tone / stamina
without drawbacks. Boost the self-esteem and sense of control.
4)
Changes in tissue perfusion associated with decreased cellular components
required for the delivery of oxygen / nutrients to the cells.
Objective:
To increase tissue perfusion
Criteria
results: - indicates inadequate perfusion, such as vital signs stable.
INTERVENTION
& IMPLEMENTATION
Monitor vital signs assess capillary refill, color of skin / mucous membranes,
nail beds.
Rational:
provides information about the degree / adequacy of tissue perfusion and help
determine the need for intervention.
Elevate
head of bed as tolerated.
Rationale:
increased lung expansion and maximize oxygenation for cellular needs. Note: if
there are contraindications hypotension.
Monitor
respiratory effort; auscultation of breath sounds adventisius note sounds.
Rational:
dyspnea, the rush to show for impaired cardiac strain jajntung as long /
compensation increased cardiac output.
Investigate
complaints of chest pain / palpitations.
Rational:
influence cellular network myocardial ischemia / infarction risk potential.
Avoid
using a bottle warmer or hot water bottle. Measure the temperature of bath
water with a thermometer.
Rational:
termoreseptor superficial dermal tissue due to interruption of oxygen.
Collaborative
monitoring laboratory test results. Give full of red blood cells / blood
product packed as indicated.
Rational:
to identify deficiencies and needs treatment / response to therapy.
Provide
supplemental oxygen as indicated.
Rational:
to maximize oxygen transport to the tissues.
5)
high risk to damage the integrity of the skin associated with changes in
circulation and neurologist.
Objective:
to maintain skin integrity.
Criteria
results: - identifying risk factors / behaviors of individuals to prevent
dermal injury.
INTERVENTION
& IMPLEMENTATION
Assess
skin integrity, record changes in turgor, impaired color, warm local, erythema,
excoriation.
Rational:
skin conditions affected by circulation, nutrition and immobilization. Networks
can become brittle and prone to infection and damage.
Reposition
periodically and massage the bone surface or if the patient does not move in
bed.
Rational:
all these skin improves circulation, limiting tissue ischemia / hypoxia affects
cell.
Instruct
the skin surface dry and clean. Limit the use of soap.
Rational:
humid areas, contaminated, providing a very good medium for the growth of
pathogenic organisms. Soap can dry out the skin excessively.
Auxiliary
for range of motion exercises.
Rationale:
increased circulation network, preventing stasis.
Use protective equipment, such as sheepskin, baskets, mattresses air pressure /
water. Protective heel / elbow and pillows as indicated. (Collaboration)
Rationale:
avoid skin damage by preventing / decreasing the pressure on the skin surface.
6)
Constipation or diarrhea associated with lower dietary input; digestive process
changes; side effects of drug therapy.
Objective:
create / return patterns of normal bowel function.
Criteria
results: - shows the change of behavior / lifestyle, which is necessary as the cause,
factor weights.
INTERVENTION
& IMPLEMENTATION
Observation
stool color, consistency, frequency and amount.
Rational:
to help identify the cause / factor ballast and appropriate intervention.
Auscultation
bowel sounds.
Rational:
bowel sounds in general increased in diarrhea and constipation decreased.
Monitor
intake and output (food and fluids).
Rational:
to identify dehydration, excessive loss or tool in identifying dietary
deficiency.
Push
the fluids enter the 2500-3000 ml / day within cardiac tolerance.
Rational:
to assist in improving the consistency of the stool when constipated. Will help
memperthankan hydration status on diarrhea.
Avoid
gas forming foods.
Rational:
reducing gastric distress and abdominal distension
Review the perianal skin conditions with frequent, record changes in skin
condition or begin to malfunction. Perform maintenance defecation perianal
every case of diarrhea.
Rational:
to prevent skin excoriation and damage.
Collaboration
siembang nutritionist for a diet with high fiber and bulk.
Rational:
fibers resist digestive enzymes and absorbing water in the stream along the
intestinal tract and thus produce bulk, which works as a stimulus for
defecation.
Give
pelembek stools, mild stimulant, bulk-forming laxatives or enemas as indicated.
Monitor effectiveness. (Collaboration)
Rational:
defecation easier if constipation occurs.
Provide antidiarrheal medications, such Defenoxilat hydrochloride with atropine
(Lomotil) and drug absorbs water, such as Metamucil. (Collaboration).
Rational:
decrease intestinal motility when diarrhea occurs.
7)
Lack of knowledge with respect to the lack of exposure / recall; incorrect
interpretation of information; does not know the source of information.
Objective:
patients know and understand about the disease, diagnostic procedures and
treatment plans.
Criteria
results: - The patient expressed understanding of the disease process and
management of the disease.
-
Identify the factors causing.
-
Perform the necessary tiindakan / lifestyle changes.
INTERVENTION
& IMPLEMENTATION
Provide
specific information about anemia. Discuss the fact that the therapy depends on
the type and severity of anemia.
Rational:
provides the knowledge base so that the patient can make the right choice.
Lowers anxiety and can improve cooperation in treatment programs.
Review
your goals and preparation for a diagnostic assay.
Rationale:
anxiety / fear of ignorance increases stress, further increasing heart load.
Knowledge lowers anxiety.
Assess
the level of knowledge of the client and family about the disease.
Rational:
megetahui how much experience and knowledge of the client and family about the
disease.
Provide
a description of the client about his illness and his condition now.
Rational:
by knowing the disease and its present state, the client and his family will
feel calm and reduce anxiety.
Instruct
client and family to watch his diet.
Rational:
diet and proper diet helps the healing process.
Ask
the client and family reiterated the material that has been given.
Rational:
knowing how much understanding of clients and their families and assess the
success of the action taken.
D.
Evaluation
Evaluation
is a systematic comparison of the patient's health or well-planned with its
intended purpose, is done by continuous, involving patients, families and other
health professionals. (Lynda Juall Capenito, 1999:28)
Evaluation
of patients with anemia are:
1)
infection does not occur.
2)
The nutritional requirements are met.
3)
Patients can maintain / improve ambulation / activity.
4)
Improved tissue perfusion.
5)
Can maintain skin integrity.
6)
Create / return patterns of normal bowel function.
7)
Patients know and understand about the disease, diagnostic procedures and
treatment plans.
REFERENCES
•
Boedihartono. 1994. Nursing Process in the Hospital. Jakarta.
•
Burton, J.L. 1990. Practical Aspects of Medicine. Binarupa Script: Jakarta
•
Carpenito, L. J. 1999. Nursing care plans and documentation of nursing, Nursing
Diagnosis and Collaborative Problems, ed. 2. EGC: Jakarta
•
Doenges, Marilynn E. 1999. Nursing care plan guidelines for planning and
documenting patient. ed.3. EGC: Jakarta
•
Effendi, Nasrul. 1995. Introduction to Nursing Process. EGC: Jakarta.
•
Hassa. 1985. Child Health, vol 1. FKUI: Jakarta
•
http://id.wikipedia.org/wiki/Anemia
•
http://www.kompas.com/ver1/Kesehatan/0611/30/104458.htm
•
Noer, Sjaifoellah. , 1998. Patient Care Standards. Monica Esther Jakarta.
•
Wilkinson, Judith M. , 2006. Handbook of Nursing Diagnosis, edition 7. EGC:
Jakarta.
